Intra-thoracic surgery : bronchotomy through the chest-wall for foreign bodies impacted in the bronchi

INTRA-THORACIC SURGERY:

BRONCHOTOMY THROUGH THE CHEST-WALL
FOR FOREIGN BODIES IMPACTED IN
THE BRONCHI.

DE FOREST WILLARD, IVLD., Ph.D.,

SURGEON TO THE PRESBYTERIAN HOSPITAL, CLINICAL PROFESSOR OF ORTHOPEDIC
SURGERY, UNIVERSITY OF PENNSYLVANIA, PHILADELPHIA.

REPRINTED FROM THE

TRANSACTIONS OF THE AMERICAN SURGICAL ASSOCIATION,
^ SEPTEMBER, 1 89 1. .

INTRA-THORACIC SURGERY : BRONCHOTOMY

THROUGH THE CHEST-WALL FOR FOREIGN
BODIES IMPACTED IN THE BRONCHI.

By DE forest WILLARD, M.D., Ph.D.,

SURGEON TO THE PRESBYTERIAN HOSPITAL, CLINICAL PROFESSOR OF ORTHOPEDIC
SURGERY, UNIVERSITY OF PENNSYLVANIA, PHILADELPHIA.

The extraction of foreign bodies that have become impacted
low down in the air-passages has always been a subject of great
surgical interest, since such impactions are necessarily of serious
import. This paper is only intended to deal with those cases
where the body has become lodged in the bronchi, as those
arrested in the larynx or trachea are much more easily reached
by surgical measures.

In order to determine the possibility of successfully reaching
the bronchus through the chest-wall, the following experiments
were instituted upon dogs, since so serious an operation demands
thorough experimental work before it is attempted upon the
human subject; and as this question may be brought to any of
us at a moment’s warning, it cannot be too speedily settled.

I approached the subject free from bias as to its possibility,
desiring only to prove or disprove its feasibility. The experi-
ments are, of course, too few in number to settle the question,
but they are placed on record as additional testimony, and to
show the extreme inherent difficulties and dangers which must
be met in our attempts to invade the thorax.

We have so successfully advanced both in cranial and ab-
dominal surgery that we are warranted in reviewing anew all
the conclusions of the past in an honest effort to secure sub--
stantial and life-giving progress in the surgery of the future.^

^ Interest in this subject has recently been reawakened by a case in a neighboring
city, where a cork half an inch in diameter became lodged at the bottom of the left

2

WI LLA RD,

My experiments thus far tend to prove :

1. That the collapse of the lung on opening the thorax,
when a lur^ has not been crippled by disease, is an exceedingly
serious and dangerous element, adding greatly to the previous
shock, and threatening at once to overpower the patient.

2. The difficulties of reaching the bronchus, especially upon
the left side, are exceedingly great and the risks of hemorrhage
enormous.

3. Incision into the bronchus necessarily leads, after closure
of the chest wound, to increasing pneumothorax, with its sub-
sequent dangers.

4. The delays in the operation from the collapse of the
patient must necessarily be great. Rapid work is impossible
when the root of the lung is being dragged backward and
forward at least half an inch in the efforts occasioned by
air-hunger, and precision is almost impossible.

5. To reach the bronchus is sometimes feasible, but to suc-
cessfully extract a foreign body from it and secure recovery is
as yet highly problematical and will require many advances
in technique. The anatomical surroundings are those most
essential to life.

Experiment I.^ Death from ether ; subsequent tracheotomy and
bronchotomy. — Large white and liver colored blind setter, weighing
seventy-five pounds. On account of his size this dog was selected,
with a view of performing tracheotomy and of introducing a foreign
body into the right bronchus, which, by reason of the large diameter
of the trachea, could readily be done.

primary bronchus. The case is reported by Dr. Rushmore in the New York Medical
Journal of July 25, 1891.

Dr. Rushmore, after two unsuccessful attempts to extract the body through the trachea,
attempted an operation for reaching the bronchus through the thoracic wall, but he was
obliged by the collapse of the patient to suspend his procedures before the chest was
actually opened.

1 These experiments have been made possible by the helpful assistance of Drs. Sailer
and Hinkle, and Mr. Nicholson, whose efficient aid and suggestions saved much loss of
time. I have also made a number of experiments in pneumonectomy and pneumon-
otomy in continuation of those made by Dr. Sailer and Messrs. Patek and Bolgiano
(Univ. Med. Mag., May, 1891, p. 473), which I shall endeavor soon to publish.

INTRA-THOR ACIC SURGERY.

3

Before the dog was thoroughly etherized, however, he suddenly
ceased to breathe, and all efforts to resuscitate him by artificial respira-
tion were unavailing. He was accordingly utilized by opening his
trachea and introducing a pebble the size of a chestnut. An opening
was then made in the chest-wall about midway between the sternum
and the spine in the fourth interspace. The trachea was easily found,
and the stone passed down into the bronchus on the left side. Search
was made for the stone, but it could not be discovered. The
bronchus was opened, the aorta being displaced to reach it, and the
pulmonary vein pushed forward. No stone could be found.

The sternum was then removed, as in ordinary post-mortem exami-
nations, but search was still unavailing. The left bronchus lay covered
by the pulmonary vein, with the aorta a little behind and to the left.
The bronchial arteries and veins were of large size and were wounded at
the right bronchus in the search. The vena azygos minor crossed so
close to the root of the lung that it would have been wounded during
any operation. This bronchus was opened, but it contained no stone.
After deliberate search through the substance of the lung, and also in
the trachea, the stone was at last found in the larynx, although the
dog had been held in a sitting position during its introduction. The
same thing happened on another dog while being experimented upon,
showing the remarkable power of reverse action in the trachea and
bronchi, if such it was.

Favier and Sabatier, in experimenting for the removal of foreign
bodies from the air-passages in dogs, also found that the objects were
always expelled voluntarily after tracheotomy, even when pushed well
down into the bronchus and buried with the forceps. They were
rejected whether the dog was lying down or upright.

Experiment IL Pebble in bronchus; bronchotomy ; death; stone
found in larynx. — White cur dog, male. Etherized, shaved, and
antiseptically cleansed. Incision was made far back toward the
spine in an endeavor to reach the bronchus from behind at the root
of the lung. Division of the skin and pectoral muscles gave but little
hemorrhage. The incision was carried back into the erector spinas
group, from which free hemorrhage occurred, requiring the use of
haemostatic forceps, ligatures, etc. The periosteum of the fourth rib
was split longitudinally, and the bone enucleated with a blunt knife
and curved hook. The fifth rib was treated in the same manner, and
an inch and one half removed from each with bone forceps. When

4

WILLARD,

the pleural cavity was reached the lung immediately collapsed
Stripping the ribs from the periosteum permitted later opening of the
chest cavity.

Before the pleura was opened tracheotomy was performed, and a
stone carried well down into the bronchus with a pair of forceps before
it was dropped. Search was then instituted, but from the time the
lung collapsed the dog was in an extremely bad condition, and died
before the bronchus could be opened, although the stone could be
easily felt in the right tube. Artificial respiration was of no avail.

After death the bronchus was opened, and although the stone had
been carried well down into place, and had been felt in that position,
yet the result was the same as reported in the previous case, the stone
being ultimately found in the larynx. By what means it had worked
its way there could not be ascertained, as the dog was upon a level
table and was not inverted.

The difficulties in securing and maintaining perfect antisepsis in
dogs are very great. Their distaste to dresssings of all kinds is so per-
sistent that the only method of enforcing continuous cleanly applica-
tions seems to be by an enveloping outside bandage of gypsum.

Experiment III. Bronchotoiny through the thoracic walls ; death in
two days. — Large, white, male bull-dog, strong and vigorous. Ether-
ized, shaved, and made antiseptic. A large incision was made on the
right side, commencing two inches from the spine, in order to avoid
the erector spinse group and to provoke less hemorrhage. One rib was
resected subperiosteally, as in Experiment II. As soon as the pleural
cavity was opened the lung collapsed, and the dog became deeply
cyanosed. Respiration was shallow, and soon ceased — the heart’s
action, however, continuing. The wound was closed with a sponge
and artificial respiration instituted. After a few minutes the color
returned in his tongue, and he was placed upon his back. This pro-
cess had to be repeated every few minutes during the entire operation.
As soon as he was turned upon his left side the weight of the lung and
the air-pressure were so great that he immediately ceased to breathe.
As the operation could not be proceeded with he was turned with
his right side uppermost, the opening was closed, artificial respi-
ration performed, and he resumed breathing. When on his back
respiration could be maintained but two minutes, and it was not
deemed safe to do tracheotomy or actually to introduce the foreign
body. The upper lobe of the lung was, therefore, turned forward.

INTKA-THORACIC SURGERY.

5

the bronchus cleared from the surrounding vessels and incised for
one half inch. Very free hemorrhage occurred from wound of the
pulmonary vein. This was controlled by hsemostatic forceps, and
afterward by chromicized catgut ligatures above and below the wound.
The opening in the bronchus was then stitched with chromicized cat-
gut, the gut being threaded upon a small, sharply curved needle.
Three interrupted sutures were thus inserted and tied. The chest
cavity was cleared of blood. The incision in the chest was then
thoroughly sponged and rendered as clean as possible. The deep
muscles were drawn together by sutures and superficial stitches added.

The dog rallied well, and on the following day ate and drank. Two
days later, however, he died. Cause unknown, as through an error
I was not notified until after he had been buried, consequently the
post-mortem examination was lost.

Experiment IV. Thoracotorny ; excision of ribs ; bronchotomy ;
ptmcfure of pulmonary vein. — Liver and white colored male dog;
weight, forty pounds. Etherized, shaved, etc. Incision on the left
side in the mid-lateral region between the third and fourth ribs.
Four inches of the fourth rib resected periosteally without opening
the chest. The pleura was then incised and the upper lobe drawn
out. As the dyspnoea in the former case was greatly relieved when
the wound in the chest was closed or rendered smaller, an attempt
was made to prevent the great inrush of air by drawing out the lobe
of the lung and passing it through a slit in a sheet of rubber-dam,
thus making an impervious veil and assisting in the relief of air-
pressure. The dam was pushed back until the bronchus of this lobe
was exposed outside of the slit. The bronchus was bare of pulmonary
vessels, and was quickly and easily incised without injuiy to them.
The amount of collapse was less than in the former case, possibly
because the left side was being operated upon, and the weight of the
heart did not press so heavily upon the left lung, as the heart was in
the reverse position. The dog suffered but little from air-hunger.
One stitch was easily placed with a curved staphylorrhaphy needle,
and matters looked favorable for a speedy and safe completion of the
operation, as the dog was doing well. In placing the second stitch,
however, a sudden movement of the root of the lung caused the point
of the needle to enter the pulmonary vein, and a gush of blood
ensued. This was conducted from the chest by the rubber-dam trough,

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WILLARD,

and the punctured vessel was seized with a haemostatic forceps and
thoroughly tied by passing a catgut ligature beneath the vein with a
blunt-pointed aneurism needle. The vein was tied above and below
the wound. The placing of the second suture was followed with like
result, the lung being dragged out of the hands of the operator during
the strong inspiratory movement. More hemorrhage ensued, but was
controlled in the same way. Other ligatures were placed, but the
blood ran into the opening of the bronchus, aad the dog was finally
killed, since there was no prospect of his more than rallying from the
operation. After death it was found that one stitch had been nicely
placed in the bronchus, and that the pulmonary vein had been torn by
the point of the second needle, but had been secured by ligature. The
bronchus was not thoroughly cleared from the surrounding structures
before incision was made, hence the accident.

Experiment V. Thoracotomy ; death from ether and collapse of lung.
— Incision on the left side opposite the seventh rib, which was resected
periosteally. Anterior part of the bronchus of the left upper lobe ex-
posed and cleared, when the dog suddenly collapsed from heart-failure,
or perhaps from pressure upon the pericardium, with probable rupture
of the septum between the lungs. Artificial respiration proved of no
avail.

In this case the posterior part of the bronchus of the middle lobe
was easily reached and seen. The aorta lay to the left, with the
pneumogastric a little posteriorly, so that it would have been easy to
have reached the bronchus. The upper bronchus anteriorly was also
easily exposed. Incision at the seventh rib is a little too low. The
bronchus had been thoroughly isolated when the collapse occurred,
and could have been easily incised. Rubber-dam was used as a
valve.

Experiment VI. Thoracotorjiy ; bronchotomy ; suturing of wound;
death fifteen minutes cifter completion of operation. — Large black and
white mongrel ; weight, thirty pounds. Incision on right side. Fifth
rib excised subperiosteally, but a serious hemorrhage occurred from
the intercostal artery, which was finally controlled by ligature. The
bronchus of the first lobe proved to be inaccessible, both anteriorly
and posteriorly, being deeply concealed and covered with the pul-
monary vessels. The bronchus of the second lobe was reached
•anteriorly and incised for one-third of an inch.

Three chromicized catgut sutures were introduced into the side of

NTRA-THORACIC SURGERY.

7

the bronchus wound and tied, a staphylorrhaphy needle being employed.
The difficulties and delays in the operation were found to be the same
as in the previous cases from the fact that resuscitation had to be
performed many times after apparent death. The dog, however, was
kept alive and the wound closed. He did not rally, and died in
fifteen minutes.

The post-mortem revealed no hemorrhage ; bronchus cleanly cut,
without injury to surrounding structures, and sutures well placed.

Experiment VII. Excision of ribs ; bronchotomy ; large pulmonary
veins ; death. — Skye terrier, male. Etherized. Incision laterally from
the point of the scapula. Fourth rib resected. A three-inch incision
on the left side. Immediate collapse of lung on admission of air.
Shock so great on collapse of lung that but little ether was subse-
quently required. The bronchus of the upper lobe found concealed
by enormous pulmonary arteries and two huge pulmonary veins which
lay in front, completely covering it. These were carefully isolated,
but the great depth of the bronchus rendered it entirely impossible to
incise it, as the vessels could not be held out of the way. The bron-
chus of the middle lobe was exposed posteriorly. The aorta and
pneumogastric lay absolutely upon it, so that operation seemed hope-
less, but it was at last incised without injury to the vessels. One
stitch was safely inserted with a staphylorrhaphy needle, but the bron-
chus being very brittle the second stitch tore out, and the dog, having
been resuscitated eight times during the operation, finally died.

The relation of the bronchus to the pulmonary vessels was found
entirely different from the previous cases, being much larger and the
bronchus deeper. The root of the lung, also, was situated low down
in the thorax, so that the incision was too high. The fifth rib would
have been better.

Experiment VIII. Simple incision of bronchus without stitching ;
death from increasing pressure of pneumothorax. — Black and white
mongrel, male ; weight, twelve pounds. Etherized, shaved, and
rendered antiseptic. Incision on the right side. Excision of the
fifth rib one inch and a half. The bronchus leading to the right
upper lobe was exposed. The bronchial and pulmonary veins were
pushed aside. Very large azygos vein. The bronchus was incised for
one-third of an inch without wounding any other structure. No
hemorrhage took place. The pleural cavity was cleaned of a few
drops of blood issuing from the divided intercostals. The intercostal

8

WILLARD,

and pectoral muscles were stitched with continuous suture of catgut,
securely closing the chest. The skin was also closed in the same
manner. The line of suture of the muscles showed a constant
tendency to bulge, and the air soon burst through it at each
inspiration. The dog breathed with comparative ease, and was rally-
ing, while the wound was partially closed. So soon, however, as
complete closure was accomplished, the dyspnoea became more
marked, the tissues being pushed out more and more at each inspira-
tion. The pneumothorax steadily increased, pushing the heart to the
left and with it the septum, thus interfering with the left lung. Death
speedily ensued.

The opening in the bronchus evidently permitted the air at each
inspiration to escape through the incision into the pleural cavity, but
from the cylindrical shape of the tube return was prevented by closure
of the slit. The action was that of a force-pump driving more air into
the pleural cavity, which is probably the explanation of the increasing
pneumothorax.

An examination of the parts after death showed that the incision
had been cleanly made in the bronchus, and that no injury had been
done to any vessel or nerve-structure in the line of the wound. There
was no hemorrhage, and death was apparently from the cause men-
tioned.

This experiment was made to observe the effect of a wound left
open in the bronchus without stitching. The increasing pneumo-
thorax seemed to be caused by the valve action of the bronchial slit.

It has been demonstrated that the air of the bronchi is septic, and
that it only becomes aseptic by the time that it reaches the bronchioles
and air-vessels.

My experiments show that upon the left side the bronchus of
dogs is enveloped by the pulmonary veins and arteries and
bronchial vessels, and although the aorta and pneumogastric
can be speedily recognized, yet the cardiac and pleural branches
of the pneumogastric run so closely to the root of the lung that
the dangers upon the living animal are simply enormous, and
in a human patient I cannot imagine a more appalling array of
difficulties than would meet the surgeon in such an attempt,
with these enormous vessels on either side and the heart in close

1 NTRA-THORACIC SURGERY. 9

proximity. Combined with the labored movement of the lung,
the operation is one beset with extreme difficulties.

On the right side, while the array of obstacles is not quite so
serious, yet the danger is increased by the close proximity of
the azygos vein, and in dogs the pressure of air upon the
septum, together with gravity, pushes the heart so far to the
left, and interferes so greatly with the action of the only lung
which is capable of rendering service at this time, that it oc-
casions greatly increased risks from apnoea.

Dr. Rushmore states that in the cadaver, however, the opera-
tion is not difficult, but expresses doubt as to the condition of
a living subject. I can say that in a dog the aspects of the
parts during life and after death are as absolutely different as
they can possibly be. A bronchus which after death is easily
exposed, and which is reached with the greatest ease, I have
seen five minutes previously absolutely enclosed with huge
pulsating vessels of twice the size, any one of which if punc-
tured would seriously complicate if not render the operation
absolutely fatal. The alteration of the parts in life and in death
can only be appreciated when seen.

I attempted a posterior entrance in a number of experiments,
but found a much more serious delay from hemorrage of the
great veins which supply the erector spinae group of muscles.

The plan of Nesiloff consists in opening the thoracic cavity
in the posterior mediastinum from behind by the resection of
the ribs without touching the pleurae. As the relation of the
parts is different in dogs, this cannot be so readily accomplished
in experiments.

The patient should be laid upon his abdomen and a vertical
incision made parallel to the vertebrae, three inches to the left;
two horizontal incisions are carried toward the vertebrae from
either extremity of the first, and the flap raised. A sub-periosteal
incision of the third, fourth, fifth, and sixth ribs is then per-
formed either by removing them or by bending them by frac-
ture, so as to replace them after the operation. The pleura is
then pushed forward and the bronchus searched for. This opera-

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WILLARD,

tion has been employed to reach the oesophagus, and it is possi-
ble that it may yet be used in searching for the bronchus/

Queue and Hartmann^ have advised the opening of the pos-
terior mediastinum by a vertical incision over the angle of the
ribs, between the spinal border of the scapula and the ver-
tebral column, about four fingers’ breadth from the spine, the
middle of the incision corresponding with the spine of the
scapula. They state that the upper lobe of the lung and the
summit of the cavity is thus made easily accessible, and that
this is a better route than the resection of the ribs below the
clavicle.

The operation has not been done, so far as I know, in man ;
and while it would be of advantage for reaching the oesophagus,
the same difficulties that have already been mentioned would be
inevitable in any operation upon the bronchus. It may serve,
however, as a route for an entrance into a tubercular cavity of
the upper ilobe — local surgical treatment of which will, in my
belief, at some future day be practicable. It may also prove
useful in reaching the vertebral bodies for caries.

In this operation the trapezius is pushed aside instead of being
incised. The ribs are excised from the second to the sixth suffi-
ciently to permit the penetration into the posterior medias-
tinum. The hilum of the lung might possibly be reached by
this route, by stripping off the pleura instead of incising it, thus
avoiding the great danger arising from the entrance of air into
the pleural cavity.

The operation which was attempted by Dr. Rushmore, but
which was not completed, was the making of a flap three
inches long and three inches wide, with its detached edge
along the left clavicle. He had cut through and pushed back
the pectoral muscles, and was about making the section of the
ribs with a saw, when he was compelled to desist his efforts in
order to revive the patient.

1 In the Journal of the American Medical Association, June 25, 1891, it is stated that
Figuiera was experimenting upon this subject by the posterior incision, but I have seen
nothing published by him.

2 Bulletin et Memoires de la Society de Chirurgie de Paris, vol. xvii, 1891, Nos. i, 2.
University Med. Magazine, July, 1891, p. 644.

INTRA-THORACIC SURGERY. II

The difficulty in extraction through the trachea in this case
was that the round body, half an inch in diameter, accurately
fitted the cylindrical bronchus, and gave no opportunity for the
forceps to grasp it unless the bronchus could be first dilated
sufficiently to allow the jaws to pass between the walls of the
tube and the cork. He employed various devices for securing
the object after tracheotomy with division of the second, third,
and fourth rings. Air-pump suction worked perfectly well in
experimenting upon rubber tubing and cork, yet it could not
dislodge the object when held by the swollen mucous membrane
of the bronchus. Instruments with concealed hooks he dis-
carded as useless on account of the impossibility of accurately
distinguishing between the cork and the mucous membrane.
This I have found an exceedingly difficult thing even with
rougher bodies than cork, as the cartilaginous rings give a firm
sensation to the probe, greatly resembling a foreign body.
Piano-wire loops were also tested by experiment on tubing, but
the loop would not pass beyond the body. Adhesive substances
were found to be useless on a moist surface. With Tiemann’s
oesophageal forceps he was able to distend the rubber tubing
and grasp the cork. These seemed the most hopeful methods
of relief offered, and they were used at the first operation. At
the second operation he thought his instrument touched the
cork. This, however, was only conjecture.

At the first operation the patient was etherized forty minutes,
when, as the object was not found, he was allowed to recover.
His temperature varied subsequently from ioo° to 103°.

The second operation was attempted five days later. The
patient labored under increasing difficulty of respiration. There
was dulness over the left thorax, and he was evidently sinking.
A corkscrew, concealed in a hollow tube, 30 French calibre,
twelve inches long, slit from end to end for the purpose of respira-
tion, was employed. This apparatus consisted of three portions,
an outer envelope, an inner tube, with two concealed spikes,
and within this a long-handled corkscrew, which could be
easily rotated. He was able to reach the cork and was
satisfied that the spikes were not fixed in the wall of the

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WILLARD

bronchus by rotating the whole instrument on its long axis.
The screw having been presumably driven into the cork, traction
was made. The coil, as was proven later, pulled from the cork.
The patient coughed up a moderate amount of bloody mucus,
and, breathing with markedly increased difficulty, became deeply
cyanosed, which cyanosis continued until the end of the operation.

The difficulty of respiration was increased, and it was believed
that the cork had passed over to the right bronchus. After ten
or fifteen minutes’ further search the anterior operation, as de-
scribed, was attempted, but abandoned. Death occurred five days
later, the condition never again warranting operative procedures.

At the post-mortem examination the cork was found at the
bifurcation of the left bronchus. The lower end of the cork was
broken off, probably before it was swallowed. The mucous
lining was sloughing and congested. Pus oozed from the small
bronchi. The lung was hepatized. The right lung was slightly
congested and oedematous. Two punctures were found upon
the upper surface of the cork, and a small piece was missing.

When a foreign body becomes impacted in the bronchus, the
gravity of the injury becomes more and more serious. Accord-
ing to the statistics of Weist and others, a large percentage of
these are fatal ultimately, either from pneumonia, gangrene,
abscess, or other complications.

On a careful physical examination to determine the site of
the impaction, the quality of the sounds elicited on percussion
will vary from slight dulness to flatness according to the amount
of blockade, and also with the nature of the body itself The
primary percussion note will not be altered except where there
is complete obstruction. Later, if pleurisy or pneumonia super-
vene, of course the ordinary physical signs will be present. If
there is entire obstruction, or if complete collapse occurs, there
will be but little, if any, movement of the ribs.^

1 Stengel (Univ. Med. Mag., August, 1891, p. 729 ; Brit. Med. Journ., April 25, 1891)
says that we can determine definitely by auscultation which bronchus is filled. If the
air does not pass in, then it is entirely occluded ; if the sounds are sibilant on inspira-
tion, the obstruction is incomplete and the opposite side will be normal. The sound
will, of course, vary as the object is tubular or solid. In partial obstruction of the
bronchus a portion of the lung may be resonant.

INTRA-THORACIC SURGERY.

13

A metallic substance will, of course, give forth a more whis-
tling sound, and peculiar-shaped bodies may occasion strange
notes. The respiratory murmur may be altered in tone — may
be extinguished or altogether lost, while upon the opposite side
respiration will usually be puerile.

The primary symptoms of bronchial impaction are usually
dyspnoea, livid face, spasmodic cough, pain in the chest, and
less interference with the voice than in laryngeal impaction.
Thoracic pain is usually present and very constant. Expiration
is ordinarily more difficult than inspiration.

The prognosis of these cases is much more serious than in
tracheal and laryngeal obstruction, and the chances of securing
the body either by operation or by voluntary expulsion are
greatly diminished.

It must be remembered that foreign bodies sometimes shift
from one bronchus to the other. The right bronchus, being
almost in line with the trachea and occupying as it does nearly
three-fifths of the area of the tube (from the fact that the point
of division lies to the left of the median line), is most likely to
receive the foreign body. Cheadle found that, in thirty cases,
sixteen were on the left side. Kocher gives Sanders’ tables of
twenty-one deaths without operative interference or expulsion,
of which ten were in the right bronchus, none in the left. In
thirty-four cases operated upon, thirteen were on the right, five
on the left.

Beleg gives thirty cases, in which nineteen were in the left
bronchus.

The right bronchus is three-quarters the size of the trachea;
the left, one-half. The right is about one inch in length ; the
left, two inches.

Voluntary Expulsion. — This is so common an occurrence
that this end should not be despaired of even when the body is
within the bronchus. Of course, this will depend somewhat
upon the character of the foreign body. Seeds of all kinds will
naturally swell under the action of heat and moisture, and may
at first occasion increasing obstruction, but as softening occurs,
expulsion may be accomplished by a voluntary effort of the

14

WILLARD,

patient. Hence the policy of non-interference in seed impac-
tion IS usually the wise course. Expulsion usually occurs in
the first few hours, but it may be delayed for weeks ; one case
is on record where a bone remained for sixty years. Secondary
expulsion may occur after ulceration and abscess, and, although
these cases even end in recovery, yet such degeneration of the
lung frequently results in death. A body occasionally becomes
encysted ; night-sweats and emaciation often follow, and the
tubercular process may be engrafted upon the inflammatory
lesion.

Inversion. — Many authors advise against inversion of the
body, but in my judgment this procedure is advisable in bron-
chial impaction, especially when the substance is metallic, and
particularly after tracheotomy, when the risk of its lodgment in
the larynx has been greatly diminished. Campbell reports a
death from hemorrhage during inversion, but this is exceptional.

Statistics of foreign bodies impacted in the bronchi show a
slightly increased percentage in favor of non-interference.
When, however, the obstruction can be located, a low trache-
otomy is justifiable with cautious attempts at extraction. These
should not be prolonged, nor should imprudent force be used.

Considerable difference of opinion exists upon the propriety
of operation in bronchial impaction. Kocher says that opera-
tion for the removal of foreign bodies is but an experiment.
Weist proves almost conclusively that nearly 90 per cent, will
recover without operation. Westmoreland favors operation
when the foreign body is in the upper air-passage, but when in
the bronchi it is not advisable. When a foreign body becomes
impacted in the bronchus, extraction is an impossibility in 78
,per cent, of cases even after tracheotomy.

Weist considers that the mortality is increased by tracheotomy
in bronchial impaction, since the risks of the operation are
added to the primary danger together with the perils arising
from the temptation in the hands of a rash surgeon to pro-
long operative efforts. ^Ulceration and perforation may result.
Small, hard bodies are the ones most liable to drop into the
bronchus, but they seldom pass beyond the binary bifurcation.

INTRA-THOR ACIC SURGERY.

15

Gross advises that not more than three attempts of one minute
each should be employed with forceps to remove a foreign
body.

The danger of the operation is largely increased by injurious
instrumentation. Thirty per cent, of the deaths following oper-
ation are from pneumonia, while this disease causes death only
in 18 per cent, of non-operative cases. Still, as Rushmore
wisely remarks, when the deaths from broncho-pneumonia are
added the results are practically similar. The failure to extract
a foreign body even after operation in 78 per cent, of cases is
certainly an unfavorable showing, but from my experiments
upon dogs, I certainly am not inclined to believe that the
chances of recovery would, be increased by approaching the
bronchus through the chest-wall.

For the purpose of extraction, forceps of various curves are
required. Gross’s, Cohen’s, Mackenzie’s, or Cusco’s lever-bladed
ones are the best. D’Etiolle’s spoon, or a bent wire, or a blunt
hook, may sometimes be required, varying with the nature of
the body to be extracted.

The forceps, though slender, should be exceedingly strong,
and should have simple serrated edges, so as not to wound the
mucous lining of the tube. After the body has been fixed by
inflammatory action, however, extraction is often impossible
with these forceps. In the case of round bodies, as peas, beans,
and peculiar-shaped substances, forceps with sharp teeth are
permissible in order to prevent slipping. The manipulations
must be performed with extreme caution, and the withdrawal
must be slow. Instruments acting upon the plan of a corkscrew
are occasionally employed, but a soft substance capable of
being penetrated by such a device would render the diagnosis
of its having been grasped an obscure one.

Suction by a Bigelow litholapaxy pump through a tube with
an open end would be useful for the removal of small articles.
Such a tube could be made much larger than the ordinary
urethral one, or rubber tubing can be employed. I am experi-
menting with a rubber tube that can be expanded so as to
occupy the entire calibre of the bronchus, and thus give strong
suction-power.

i6

WILLARD,

After tracheotomy the wound should be kept open by blunt
hooks or by stitches, never by a canula, which would block the
exit and prevent the voluntary expulsion which is so common
even after failure with instruments. The dressing should be
simply loose gauze, to exclude the dust without interfering with
the exit. The air should be heated after the operation to 8o°
or 85°, as I am satisfied from experience that all tracheotomies
do better in a high temperature.

When the opening in the trachea gives entire relief from
dyspnoea, it is very improbable that any object is fastened in the
bronchus. Tracheal mirrors with electrical illumination, as well
as laryngeal ones, should be employed in the diagnosis after
tracheotomy. The greater the extent and duration of the dys-
pnoea the greater will be the danger from pneumonia after
tracheotomy.

The work of Avonssohn, Gross, Durham (Holmes* Surgery),
Weist, and others have made possible many successful results.^
It is certainly impossible for any surgeon to diagnosticate before-
hand whether his individual case is one of those in which the
obstruction will be loosened and coughed up, or whether it will
remain, producing gangrene, pneumonia, or subsequent abscess,
consequently each case should be most thoroughly considered.

Bronchus originally meant the windpipe, while the two pri-
mary divisions were named "bronchia, hence the term bronch-
otomy was used to designate any opening in the air-passages of
either larynx, trachea, or bronchus ; and Gross and other
writers, even as late as Weist, still use the term to designate
the high operation. It should be confined to operation upon
the bronchus, as laryngotomy and tracheotomy properly desig-
nate these higher operations.

Weist (Trans. Amer. Surg. Assoc., Vol. I.) gives an accurate
and careful analysis of 1000 cases of foreign bodies in the
larynx, trachea, and bronchus, as will be remembered by all the
members of this Association. In it he shows conclusively that
the simple presence of a foreign body is not an absolute indica-
tion for operation, as had been previously held by most surgical

^ Bourdillat gives a large collection of cases (Poulson, On Foreign Bodies," p. 33)
Also, Maurice Perrin gives statistics.

INTRA-THORACIC SURGERY.

17

teachers. While operation is the rule, yet there are modifying-
circumstances. His conclusions were that 76 per cent, of non-
operative cases recovered, and 72 per cent, of those operated
upon, but, of course, the latter were the worst class, as the former
included many in which early expulsion took place. Weist
does not advise opening simply because a foreign body is
present ; there must be some other indications. He advises
non-interference when a foreign body remains quiet and the
symptoms are not serious, but favors operation when the body
is movable and when there are frequent attacks of suffocation.

Smith gives 1600 cases, with 70 per cent, of recoveries of
non-operative cases and 76 per cent, of operative ones, the pro-
portion being one death to every three and a half cases not
operated upon, and one death to every four of those operated
upon.

Durham gives 50 per cent, of recoveries in non-operative
cases and 77 per cent, of operative ones ; also, he gives 74 per
cent, of tracheotomy recoveries. Guyon and Durham, in 1674
cases, give 70 per cent, of recoveries in non-operative cases and
75 per cent, in operative ones.

Medico-legal cases arise in connection with impacted objects
in the bronchi, as death is sometimes sudden. Only a few days
since a mother was arrested for killing her child. Post-mortem
revealed the fact that during the operation of spanking, the
child had swallowed a button, which had caused almost im-
mediate death by lodgment in the bronchus.

Conclusions. — i. The bronchus in dogs can be reached either
anteriorly or posteriorly through the chest-walls, but its ana-
tomical position is in such close proximity to large and im-
portant structures that safe incision is a matter of extreme
difficulty and danger.

2. Bronchotomy through the walls of the thorax is an opera-
tion attended with great shock from collapse of the lungs, and
until technique is further advanced is liable to result in im-
mediate death.

3. Collapse of the lung is more serious in a healthy organ
than in one previously crippled by disease.

2

i8

INTRA-THORACIC SURGERY.

4. The serious inherent difficulties are shock, suffocation from
lung collapse, enormous risks of hemorrhage from pulmonary
vessels, injury of or interference with the pneumogastric, great
and fatal delays owing to the exaggerated movement of the
root of the lung caused by the excessive dyspnoea.

5. Closure of the bronchial slit is slow and dangerous. To
leave it open causes increasing pneumothorax by its valve action,
and also permits the entrance of septic air into the pleural
cavity.

6. Although a foreign body can be reached by this route, yet
removal is hazardous. To secure a subsequent complete cure
seems in the present state of knowledge very problematical.

7. When the presence of a foreign body in the bronchus is
definitely determined, and primary voluntary expulsion has not
been accomplished, there is great danger in permitting it to re-
main, even though it may but partially obstruct the tube. The
risks both of immediate and of subsequent inflammation are
serious.

8. Low tracheotomy is, then, advisable when the presence of
a foreign body is certain ; it adds but little to the risk, and
affords easier escape for the object even when extraction is not
feasible.

9. Subsequent da7igers arise from severe and prolonged instru-
mentation, not from tracheotomy.

10. Voluntary expulsion is more probable after than before
tracheotomy.

11. Tracheotomy is permissible even after an object has been
long in position, unless serious lung changes have resulted.

12. The question of tracheotomy will depend largely upon
the form, size, and character of the foreign body.

13. The term bronchotomy should be limited to an opening
of the bronchus, and should not be employed to designate
higher operations.

14. The risks from thoracotomy and bronchotomy following
unsuccessful tracheotomy are much greater than the dangers
incurred by permitting the foreign body to remain.